Do not try to run before you can walk

This issue of the European Journal of Cardio-Thoracic Surgery includes an interesting review of 3819 matched pairs of early-stage lung cancer resections from the National Cancer Database in the USA [1]. The authors conclude that the safety and efficacy of early discharge on postoperative day 1 following lobectomy is associated with the institutional surgical volume in lung cancer resections. According to their results, the risk of adverse events (unplanned 30-day readmission and 90-day mortality) is significantly higher in centres accounting for less than 17 lobectomies per year or, in other words, <2 cases per month! With such numbers, the surgical team (the whole team, not only surgeons) expertise in preventing and solving postoperative adverse events after lung resection can be suspected very limited and establishing a first postoperative day discharge program seems to be risky for the patient and expensive for the health system due to high rate of readmissions.

The variable length of stay (LOS) is not necessarily directly correlated to quality of care. According to Clarke [2] above and below a certain optimum LOS, quality of care may deteriorate, and the optimum LOS depends on the individual patient’s needs.

Today, in many centres, work is done under strong pressure with the aim of reducing LOS. Besides the evidence that unnecessary hospitalization increases the risk of nosocomial infection [3], it is argued that the cost per procedure depends to a large extent on the hospital stay and, therefore, by decreasing this, the surgical process is cheaper. This argument is incontestable, but very few articles dealing with the subject consider other aspects of the problem that would merit in-depth study.

In Drawbert et al. paper [1], the median age of studied cases is 68. Around 1 out 4 of people over 65 live alone both in Europe and the USA [4, 5] and the percentage of people living alone increases with age. Thus, family support for the patient is expected to be low after hospital discharge. A recently published study [6] concluded that one-tenth of older adults patients not using home care before cancer surgery became dependent on long-term home care, indicating a change in dependence status. In the study, a first phase of home care is identified focused on nursing care in the first postoperative year.

In 2019 the mean costs of home care for older dependent adults in Europe for 12 months is €36 442 [7], and although this figure is not directly related to patients immediately after lung cancer surgery, it can give us an estimation on how expensive for the society can be discharging patients without checking their adequate physical and mental status after lung resection. Besides, the effectiveness of nursing home visits remains a matter of uncertainty and their cost-effectiveness is also uncertain.

In the study by Drawbert et al. [1], it is clearly shown that centres performing a high number of cases per year can guarantee patients safety for early discharging programs based, as hypothesized by the authors, on the implementation of Enhanced Recovery After Surgery protocols. If case number is not high enough, the consequences of running for discharge can have disastrous consequences not only for patients but also for healthcare systems.

Conflict of interest: none declared.

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